WHY YOU DON’T ARGUE WITH A PERSON WITH DEMENTIA OR DELUSIONS

The elderly person with dementia, who has a persistent fixed incorrect idea or delusion, is literally unable to change their mind. The idea might be harmless, as in the case of the elderly woman who insisted she was always on a train. Or it might be dangerous as the person who is insisting he has to leave and go to work, when he hasn’t worked for many years. Harmless or not, these ideas frighten the family or caregiver because it demonstrates irrational thinking.  Using rational explanations or arguing doesn’t work when the person is unable to change their mind.

5 ways to address delusions without arguing:

  1. Let it go if at all possible. If the idea is not dangerous, doesn’t bother the person or others, let it go.
  2. If the idea or delusion is frightening, such as the woman who thought people were living on her patio, give reassuring , comforting words. “I am here and will stay with you,” while you use a distracting activity.
  3. A delusion might be an expression of some fear. Look to the environment. Are there shadows, do you need more light, are curtain or shades open at night creating reflections on a window?
  4. Support the feelings the person expresses, not the delusion.
  5. Ask the person to show you what they see. The shadow on a wall, when reality is distorted, may become a ghost to the confused.

Many delusions are just plain hurtful, as with the spouse who is no longer recognized and is accused of being an impostor. Some delusions are very embarrassing for the family, and require understanding and the education of others.  Well meaning friends and acquaintances may intercede and begin arguing the irrational  idea or delusion. Look at this as an opportunity to educate other people, so that they may support you, in creating your plan of care for this person.

When caring for the individual with irrational ideas, you never argue these thoughts away.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

DRUGS AND DELIRIUM

Anti-psychotic medications are routinely prescribed for delirium. However if the delirium is due to anesthesia, a drug, an electrolyte imbalance or infection and the effects will wear off relatively soon. It would be much wiser given the side effects, to just have someone stay with the individual. Non-drug support works much more effectively especially with the elderly than introducing yet another drug.

Side effects are far ranging such as; loss of balance, restlessness, trembling, difficulty urinating, weakness, dizziness, skin rash, and even unusual movements of the mouth, arms and legs. When these drugs are used, the family member should be given a complete list of the drugs side effects.

Delirium is a very frustrating condition for the patient. It causes misinterpretation of their environment. Keeping the patient informed of what day it is, what time of day it is, what has happened, where they are and what is going on right now is very important. Often if the patient is hallucinating they will tell you that they know what they are seeing, can’t be true, but they are seeing it anyway.

These drugs may be introduced just because it is difficult to care for someone who is delirious. However many elderly people being discharged from the hospital, are now leaving on powerful anti-psychotic medications due to delirium. The problem arises when the patient is no longer delirious due to the infection, surgery or medical condition that caused it in the first place. But now they are suffering from the side effects of the drug.

What does work for delirium? Studies now show that the quickest way to recover from delirium is to get moving. Having patients get out of bed and start walking it off, turns out to be the best and safest medicine yet. Make sure the patient is hydrated, there is a reason patients come out of surgery with IV solutions. Make sure the patient is exposed to sun light during the day and in a dark room at night so that they return to their normal sleep/awake cycle.

And most of all provide that one on one caregiver, who can explain the environment while reassuring the patient that all is well and they are safe.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

DEMENTIA AND DELIRIUM INCREASE CHANCE OF FALLS

Confusion due to dementia and delirium are known risk factors for falls in healthcare. Researches have noted that persons with confusion have a risk of falling 1.8 times that of the elderly without dementia. Falls in the elderly are predictable when the elder has; balance problems, problems with dizziness or fainting, cardiac problems, arthritis, osteoporosis, vision problems, is weak from immobility or a recent infection, is taking numerous medications or a medication for anxiety, or depression.

But the risk of a fall increases to almost double the risk when the elderly have dementia or delirium as well as the other known risk factors.

Behavioral problems – the person with dementia or delirium will have decreased safety awareness and make poor decisions. The person with dementia or delirium are more likely to forget to use assistive devices such as canes and walkers, or stop and put on good safe footwear. If the person also experiences angry outbursts of a physical nature, this also greatly increases their risk of falling.

Dietary deficiency –  the person with dementia or delirium can suffer from a poor nutritional status due to bad food choices. Adequate protein, essential vitamins, and water are needed for good health.  And especially vitamin D and calcium are necessary for strong bones.

Vision changes – a person with dementia can experience a decline in the ability to sense where they are in space. This often results in sitting down and missing a chair. Added to that a decrease in visual accommodation to light and dark, glare intolerance, altered depth perception and possibly physical changes in eyes due to aging, increase the risk of falls to an even greater degree.

Chronic illness – arthritis causing stiffening of joints, osteoporosis and bone deterioration increases risk of injury related to a fall, stroke and Parkinson’s disease increase the risk of falls. These are known issues with aging, and the elder with dementia who has painful swollen joints from arthritis is at even more risk.

Acute illness – has been shown to be a factor in 10% to 20% of falls in the elderly. An acute infection will cause weakness, fatigue, even dizziness. But the person with dementia or delirium will have an increase in their confusion.

Continuous monitoring of the elder with dementia or delirium is necessary as well as monitoring for these increased risk factors.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

TEMPORARY DEMENTIA – REVERSIBLE DEMENTIA REALLY?

Really, there are some conditions that cause temporary dementia and are reversible. While there are many diseases or physical conditions that can cause dementia, some are reversible. Seeking medical assistance as soon as possible may make the difference in preventing any permanent brain damage.

Delirium often times resembles dementia so much so, that someone who knows the elder is very necessary to give a history, of the recent state of confusion. Dementia from a disease process develops slowly over time. However delirium may develop within hours, in the elderly. Knowing what is normal for the elder and the speed at which he became confused, is a significant part of the diagnosis. Many things can cause delirium, frequently in the elderly it is an infection. As well as the elder who becomes confused every time they are in the hospital, due to anesthesia.

Medications , when looking for the cause of sudden confusion, referencing the list of medications that can cause delirium is a good place to start. As the liver and kidneys age they are less able to remove medications from the body and the elder gets a build up of toxins. Added to this may be declining health and the number of medications our elders are now taking, can set the elder up for developing delirium, and a diagnosis of dementia.

Brain Tumor, the first symptom of slow growing brain tumors in the elderly, very much resembles dementia. Brain tumors are know to cause changes in cognition and even personality changes.

Depression, some people with depression may complain of forgetfulness, they looks sad or worried, have trouble concentrating, and look depressed. The important thing to notice is was the person depressed and then became confused? Or was the person experiencing mental decline, and that is what caused the depression. If in fact the depression came first, the symptoms that followed can be reversed when the depression is addressed.

Vitamin B12 deficiency, or pernicious anemia will cause confusion, slowness, irritability and the person appears to have lost their get up and go. Even though vitamin B12 is plentiful in the American diet, this deficiency develops because the elder can no longer absorb the vitamin and requires injections.

Water on the brain, hydrocephalus, an excess of spinal fluid around the brain. This can be caused by a head trauma, but usually begin without an obvious cause in the elderly. The elder literally slows down, walking as if their feet are stuck to the floor. They will lose bladder control as well as become confused. If the condition is caught early and a shunt is put in place to drain the fluid, the person can return to previous level of function.

As always, early identification of changes as well as quick intervention is the answer to mental recovery.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

WHAT IS THE E IN CTE? IS THAT THE SAME AS DELIRIUM? A CONCUSSION?

The C is for chronic, happening over and over. And the T is for traumatic, meaning this isn’t just a little bump on the head, it is a repeated injury.  But that E is a problem in healthcare. E is for enchephalopathy.  Since the movie Concussion came out more people are aware of the high cost of getting repeatedly hit in the head. This could be for any reason, where a person sustains head injury. From having epilepsy, and during seizures, hitting your head on hard surfaces, to boxing head injuries, sports injuries and now to the current focus of playing football.

The reason it is difficult to differentiate between delirium and enchephalopathy is because even the medical community seems to use these terms interchangeably. The common use of delirium is an altered mental state, well so is it for enchephalopathy. It is only when a person needs that diagnosis for reasons of medical insurance or healthcare intervention that things get more specific.

Much easier to see than a physical injury, is when delirium relates to the abuse of alcohol. The person who is drunk may be unsteady on their feet, having balance problems to the point of walking into things and even falling down. Their thinking will be foggy, unable to communicate their thoughts clearly. In fact their speech can be slurred as well. The next day they may have no memory of the events of the day before, while they were drunk.

If that person continues to abuse alcohol over a long period of time the damage to the brain would no longer be considered delirium. Those changes are no longer happening quickly, and no longer reverse, now they are a permanent change in the person’s brain.

And so, also for that football player who sustains a significant hit to the head, they might have a mild concussion. They might be unsteady on their feet and be confused for awhile. But after repeated abuse, just as with the alcoholic, the changes over the years may be subtle and develop slowly. But the end result could be the same. Poor judgement, poor coordination, gross distraction, tremors or muscle twitching and dementia.

Virginia Garberding RN

Certified in Restorative Nursing and Gerontology

FAST ONSET DEMENTIA – PROBABLY DELIRIUM

PART II

Delirium is a sudden change in a person’s mental abilities and is common in the elderly with acute medical illness. The elder with dementia will have a greater risk of developing delirium when ill, than the elder without dementia.

Delirium can be caused by infections, pain, sleep deprivation, dehydration, metabolic or electrolyte disturbances, constipation, and many times medications especially psychoactive medications. The evaluation process can be extensive because of the large number of possible causes.

Finding out the cause of the delirium is the first priority. Once the medical cause is brought under control it will usually still take some time for the delirium to resolve, even months.  During the time of recovery it is important to:

  • Provide optimal nutrition and hydration
  • Ensure the elder’s safety
  • Encourage a routine sleep – wake cycle
  • Provide a calm environment
  • Make sure that eye glasses are clean, hearing aids are working and dentures are in.
  • Provide good lighting, even during the day keep lights on
  • Simplify – reduce clutter, noise, few visitors

 

In his later years my father would become delirious every time he was hospitalized. I would position myself in front of him, smile and reassure him all was well. When staff would come into the room I would introduce them to Dad and tell him why they were there and what they were doing. I avoided side conversations with staff or visitors and only concentrated on Dad. When he recovered he would remember the bugs running up and down the walls, but he would also remember me just sitting there smiling.

 

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

 

FAST ONSET DEMENTIA – PROBABLY DELIRIUM

PART I

THE DEFINITION OF DELIRIUM: A condition of acute and sudden onset of impairment of attention, memory, orientation, language usage, consciousness, perception, behavior and/or emotions that may fluctuate. This is a condition that is directly related to a medical cause and is not due to dementia. It is often called “acute confusion.”

This is not the confusion associated with a terminal condition that occurs in the days before dying. This “terminal delirium” is irreversible and often calls for the use of anti-psychotic medications for the comfort of the patient. Sudden onset delirium is reversible and requires testing for possible cause.

Delirium caused by a medical condition is often confused with dementia and requires a clear history from the family. The areas to report to your healthcare provider are;

  • Is the person more confused today than yesterday? Was this a sudden change in the person’s mental status? If the person is more confused and the increase came on suddenly, you need to consider delirium.
  • Is the person more easily distracted, unable to focus his attention or unable to follow what is being said, than previously? A person with mild cognitive impairment can usually say the days of the week backwards or recite the months of the year backwards. The person with delirium is too distracted to focus on a task like this.
  • Is the person’s thinking disorganized or incoherent? Is the person rambling, has an illogical flow of ideas, or engages in irrelevant conversation? Ask the person a few questions to assess their train of thought:
  1. Will a stone float on water?
  2. Are there fish in the sea?
  3. Does one pound weigh more than two pounds?
  4. Can you use a hammer to pound a nail?

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing